Alternate Method for Length-Unstable Femur Fractures

(From the November 2013 Issue of PediatricsOnline)

A new study of children with femur fractures suggests that a surgical technique for submuscular bridge plating using precontoured plates may offer better outcomes for patients than many conventional methods. The findings, from a team of orthopedic surgeons at Nationwide Children’s Hospital, were published in the September issue of the Journal of Pediatric Orthopedics.

Proper surgical management of pediatric femur fractures has long been debated. Many methods allow length-unstable fractures to shorten, malalign or re-fracture, and some techniques require extended hospital stays due to damage to tissue or bones. The technique used with patients in this study may offer a simple solution to the management of these injuries, says Kevin Klingele, MD, chief of Orthopedics at Nationwide Children’s and senior author of the study.

“Submuscular plating offers a safe and effective means of managing femur fractures in this age group, especially with fractures that often pose the most risk to the patient,” says Dr. Klingele. “The stable fixation allows early weightbearing without postoperative immobilization and has shown quick recovery.”

The 32 patients in the study suffered 33 fractures from injuries such as falls, recreation mishaps and motor vehicle accidents. The fractures included 13 comminuted, five spiral, nine long oblique and six short oblique, on 15 left femurs and 18 right femurs.

The surgical treatment provided in each case involved precontouring the plate to the patient’s femur using fluoroscopy and a table top bender. The plate was inserted along the shaft of the femur through two small incisions and held in place by cortical screws in the proximal and distal ends. Locking screws were added and the placement of the plate and screws were confirmed by fluoroscopy and direct visualization.

Surgeons found that the technique decreased the need for percutaneous screws, simplified both implantation and removal, and reduced radiation exposure and fluoroscopy time. No intraoperative complications occurred, although six patients needed percutaneous fixation. Patients returned to activity when able (mean, 7.8 weeks), and all patients were radiographically healed by 12 weeks post-surgery. None of the patients experienced varus or valgus malalignment greater than 10 degrees, and no wound infections occurred.

Removal of the plate occurred for 26 patients between six months and one year post-surgery. In two children, broken screws were discovered during the removal of the plate but were left in place due to the possibility of re-fracture.

“This study verifies clinical outcomes of a straightforward technique,” says Dr. Klingele. “At our facility, it has become standard of care for management of these injuries and has shown very low complication rates and excellent outcomes.”

Although multiple surgical treatment options exist for length-unstable pediatric femur fractures, submuscular plating with precontoured plates appears to be a valid and appealing option, he adds. The lack of malalignment and surgical complications (with follow-up ranging from 27 to 294 weeks) also suggests this plating technique may help avoid common problems with other surgical methods.

“Longer follow-up and randomized comparative studies with previous techniques may help solidify the belief that, at this point, submuscular plating is often the best option for these injuries,” says Dr. Klingele.